A pediatric SOAP note records a sick visit: the history from the caregiver and child, an exam read against age norms, and a plan with weight-based doses. Copy the free template, see two filled examples, and check what each section needs.
Blank pediatric SOAP note template
FreePEDIATRIC SOAP NOTE Patient: [Name] Date of birth and age: [Date; age in years and months] Date of visit: [Date] Visit type: [Sick visit, recheck, or telehealth] Accompanied by: [Caregiver and relationship to the child] History from: [Caregiver, child, or both; interpreter if used] Clinician: [Name, credentials] SUBJECTIVE Chief complaint: [Main concern, in the caregiver's or child's words] History of present illness: [Onset, duration, course, associated symptoms, pertinent negatives] Fever: [Days of fever, highest reading, how it was measured] Intake and output: [Drinking and eating compared with usual; wet diapers or voids in 24 hours; vomiting or diarrhea] Behavior: [Activity, play, sleep, irritability, whether consolable] Child's account: [What the child reports, if old enough] Treatments given: [Medicines given at home, with dose and time of the last dose] Exposures: [Daycare or school, sick contacts, travel] Background: [Birth history if relevant, chronic conditions, immunizations up to date per local schedule or not] Medications: [Regular medicines with doses] Allergies: [Drug, food, and other allergies, with reactions] OBJECTIVE Weight: [kg and lb, percentile, date weighed] Vital signs: [Temperature with route, HR, RR, SpO2, BP if indicated, read against age-based ranges] General appearance: [Alert, interactive, consolable, well or unwell appearing] Hydration: [Mucous membranes, tears, capillary refill, fontanelle in infants] Examination: [Findings by system for the complaint, plus ears, throat, chest, and skin in a febrile child] Point-of-care tests: [Results, if done] ASSESSMENT Diagnosis: [Working diagnosis and the findings that support it] Serious causes considered: [What was ruled out for this age, and how] Severity: [Mild, moderate, or severe; degree of dehydration] PLAN Treatment: [Drug, mg/kg dose, calculated dose in mg and mL with the concentration, route, frequency, duration, daily maximum] Supportive care: [Fluids, comfort measures, skin or nasal care] Caregiver education: [What was explained, and the caregiver's understanding] Return precautions: [Specific signs that need urgent review or emergency care] Daycare or school: [When the child can return] Follow-up: [When and with whom, or as needed] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Pediatric clinic, same-day sick visit
2-year-old boy with fever for 2 days, and cough and runny nose for 3 days. History from his mother. Highest temperature 39.2 °C (102.6 °F) by ear thermometer last night. Drinking well but eating less; 5 wet diapers in the last 24 hours, about his usual. Playful when the fever comes down. No fast or noisy breathing, ear pulling, vomiting, diarrhea, or rash. Attends daycare; his older sister has a cold. Acetaminophen 160 mg (5 mL of 160 mg/5 mL) given 4 hours ago. Born at term, no chronic conditions, immunizations up to date per local schedule. No regular medicines. No known drug allergies.
Weight 12 kg (26.5 lb), 40th percentile, following his curve. T 38.6 °C (101.5 °F) tympanic, HR 130, RR 28, SpO2 98% on room air. Alert, interactive, playing on his mother’s lap. Moist mucous membranes, tears present, capillary refill under 2 seconds. Clear nasal discharge. Ear drums gray and translucent with normal landmarks on both sides. Throat mildly red, no exudate. Neck supple. No retractions or nasal flaring; good air entry, no crackles or wheeze. Skin warm and well perfused, no rash.
Viral upper respiratory infection, day 2 of fever, in a well-appearing, well-hydrated child immunized for age. No signs of acute otitis media, pneumonia, or meningitis: ear drums normal, breathing rate and oxygen normal with a clear chest, neck supple, and fully interactive. No tests needed today.
For discomfort or fever: acetaminophen 15 mg/kg = 180 mg, 5.6 mL of 160 mg/5 mL every 4 to 6 hours as needed, no more than 5 doses in 24 hours; or ibuprofen 10 mg/kg = 120 mg, 6 mL of 100 mg/5 mL every 6 to 8 hours as needed with food or drink, no more than 4 doses in 24 hours. Explained that the aim is comfort, not a normal temperature. Fluids, saline nose drops before feeds and sleep, and honey, half a teaspoon at bedtime, for the cough. Over-the-counter cough and cold medicines not recommended at his age. Return or seek urgent care for fast or labored breathing, ribs pulling in with breaths, fewer than 3 wet diapers in 24 hours, unusual sleepiness, a rash that doesn’t fade when pressed, ear pain, or fever lasting more than 3 days in total. Back to daycare when fever-free for 24 hours without medicine. Follow-up as needed.
Pediatric clinic, sick visit
7-year-old girl with eczema since infancy, seen with her father for an itchy rash that has flared over 2 weeks, since the weather turned cold and dry. Itch worst at night, waking her 2 to 3 times; tired at school. She says it itches most in class and at bedtime. Moisturizer once a day, some days missed. Hydrocortisone 1% cream for 3 days with little change. No fever, oozing, crusting, or painful blisters. Seasonal allergic rhinitis; her father has asthma. Immunizations up to date per local schedule. No regular medicines. No known drug allergies.
Weight 23 kg (50.7 lb), 55th percentile. T 36.8 °C (98.2 °F), HR 86, RR 18. Well and playful. Dry, red, scaly patches with thickened skin and scratch marks in both elbow and knee creases and on the sides of the neck, about 6% of body surface. No weeping, honey-colored crusts, pustules, or punched-out erosions. No enlarged lymph nodes. POEM, completed with her father: 14, moderate.
Atopic dermatitis, moderate flexural flare, triggered by dry weather and missed moisturizer. No signs of bacterial infection or eczema herpeticum. Sleep disrupted by itch.
Thick fragrance-free moisturizer all over at least twice a day and after bathing. Short lukewarm baths with a gentle soap-free cleanser; pat dry. Elbow and knee creases: triamcinolone 0.1% ointment twice a day for up to 7 days, stopping as the skin clears. Neck: hydrocortisone 1% ointment twice a day for up to 7 days. Amounts explained in fingertip units; written eczema plan given. Cotton clothing, nails kept short. Not contagious, so school as usual. Return sooner for weeping, yellow crusts, a painful or fast-spreading rash, or fever, and the same day for clusters of blisters or punched-out sores. Follow-up in 2 to 4 weeks to review the response and plan maintenance.
What the caregiver and, when old enough, the child tell you. Start by naming who gave the history.
Avoid: “Fever” with no number or method. A measured 39.5 °C and a child who felt warm are different histories, especially in a young infant.
Weight comes first: every dose and fluid calculation depends on it. Then the vital signs, read against the normal range for the child’s age.
Avoid: Reading vital signs against adult ranges. A breathing rate of 40 is normal at 6 months and fast at 10 years.
The diagnosis, how unwell the child is, and the serious causes you considered for this age.
Avoid: Leaving out what you ruled out. “No signs of pneumonia or meningitis” shows the reasoning behind a plan to manage at home.
A plan the caregiver can follow at home and the next clinician can check, with every weight-based dose worked out.
Avoid: “Weight-based dosing” with no numbers. Write the weight used, the mg/kg, and the mL, so anyone can check the math.
Weigh the child at every sick visit. Last year’s weight or a caregiver’s guess can make a dose too low to work or high enough to harm.
A toddler’s history comes from a caregiver; a school-age child can add their own. Name the source and note an interpreter, so the reader can weigh the history.
Record intake compared with usual, wet diapers or voids in 24 hours, and the exam signs. Numbers let the next clinician see a change.
Write the specific signs you told the caregiver to watch for, and how quickly to act. If the child comes back, the note shows what the family was told.
Liquid medicines come in more than one strength. Write the concentration with the mL, such as 6 mL of 100 mg/5 mL, so the dose is clear to the caregiver and the pharmacy.
Vero Scribe writes the pediatric SOAP note in your template from the visit conversation, with the caregiver’s consent, or from your dictation. You check the weight and doses, edit, and copy it into your chart or EHR.
The four SOAP sections, plus who gave the history, the child’s weight with its percentile, vital signs read against age-based ranges, hydration status, weight-based doses with the calculation shown, and the return precautions given to the caregiver.
Write the weight in kg and when it was measured, the dose in mg/kg, the calculated dose in mg, and the volume for the concentration, such as 6 mL of 100 mg/5 mL. Check it against the maximum single and daily dose, and never exceed the adult dose.
Usually a parent or caregiver for young children, with the child adding their own account as they get older. Record the source, and whether an interpreter was used.
Yes. Teenagers usually give their own history; note any part taken without a parent present, following your local consent and confidentiality rules. Keep dosing by weight until the child reaches adult doses.
Yes. Copy it, or download it as a Word or text file. No account needed.
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